Min Kyu Yang,Namju Kim, Ho-Kyung Choung, Sang In Khwarg
To evaluate the effect of a topical steroid instillation on recently developed incomplete nasolacrimal duct obstruction (NLDO) evaluated by using anterior segment optical coherence tomography (ASOCT).
Forty-nine eyes of 31 patients with incomplete NLDO who developed epiphora within 3 months were recruited and treated with a topical steroid for 3 months. Tear meniscus height (TMH) and area (TMA) were measured by ASOCT. The treatment was considered to be effective when there was improvement of subjective epiphora, normal tear meniscus on slit lamp examination, a fluorescein dye disappearance test with grade 0 or 1, and TMH < 250 μm on ASOCT. The treatment effectiveness and associated factors were analyzed.
Treatment was effective in 24 eyes (49.0%) after 6 months of follow-up. TMH and TMA at 3 months were significantly decreased in the effective group on ASOCT (TMH: from 385 to 268 μm, p = 0.002, TMA: from 0.0564 to 0.0266 mm2, p = 0.001, Wilcoxon test). In the effective group, the eyes with normal tear meniscus at 1 month were significantly more frequent than those in the ineffective group (p < 0.001, Fisher’s exact test). No patient in the effective group required further invasive management during 3 years of follow-up.
Topical steroid instillation has a significant therapeutic effect on recently developed incomplete NLDO. Additional invasive procedures were avoided in half of the subjects.
Alsoudi, Amer; Copperman, Thomas S.; Idowu, Oluwatobi O.; Kersten, Robert C.
A 68-year-old man with known history of IgG4-related disease presented with a 1-year history of mucoid discharge OD and progressive proptosis OS. MRI showed diffuse enlargement of the left lacrimal gland along with prolonged infiltrative changes involving the left extraocular muscles, supraorbital nerve, and infraorbital nerve. No identifiable masses were noted in either nasolacrimal drainage system on MRI. Due to clinical evidence of nasolacrimal duct obstruction, a right external dacryocystorhinostomy was performed along with biopsies of the right lacrimal sac and left lacrimal gland. Immunohistochemical stains identified IgG4-positive plasma cells in the biopsy of the right lacrimal sac indicative of secondary acquired nasolacrimal duct obstruction despite the absence of mass forming lesions on exam and nasolacrimal imaging. This report is the first to describe nasolacrimal drainage system IgG4-related ophthalmic disease involvement in an otherwise clinically and radiographically normal appearing tear drainage system.
Sarina K. Mueller, Suzanne K. Freitag, Daniel R. Lefebvre, Nahyoung G. Lee & Benjamin S. Bleier
Background: Endoscopic dacryocystorhinostomies (eDCRs) show patency rates between 81% and 94%. However, dacryocystorhinostomy (DCR) failure and the need for revision remain a significant challenge. One of the principal challenges in revision eDCR is the need to surgically identify the correct osteotomy site and maintain long-term patency in the setting of previously instrumented and potentially scarred tissue. At the same time, the surgeon must assume that the blood supply to the commonly described anterior and posteriorly pedicled flaps has been compromised.
Objective: The objective of the study is to describe a novel flap technique for revision eDCR.
Methods: The superior based mucosal flap is a novel technique that provides a vascularized mucosa preserving technique in revision eDCR despite previous instrumentation of the lacrimal system. This technique provides wide exposure of the revision osteotomy site while simultaneously allowing a viable mucosal flap to be replaced at the conclusion of the procedure, thereby minimizing bone exposure and cicatricial restenosis.
Results: The authors have utilized this technique in 13 procedures with 100% positive identification of the lacrimal sac, a 0% complication rate, and a 100% success rate after a mean follow-up of 26.93 ± 10.33 months (range 6–35 months).
Conclusion: The eDCR using the superior pedicled mucosal flap provides excellent exposure of the maxillary bone and the lacrimal sac. This method preserves vascularity of the flap using a superiorly based pedicle which is typically inviolate during both open and endoscopic primary DCR. The mucosal flap can then be replaced, thereby minimizing bone exposure and optimizing patency.
Kosuke Ueda, Akihide Watanabe, Norihiko Yokoi, Manabu Sugimoto, Hideki Fukuoka, Katsuhiko Shinomiya, Shigeru Kinoshita, Saul Rajak & Dinesh Selva
Purpose: The purpose of this article is to present a novel technique, as well the histopathological findings, of dacryoendoscopic guided nasolacrimal duct (NLD) biopsy for recurrent nasolacrimal duct obstruction (NLDO).
Methods: This study involved subjects with recurrent NLDO. Direct endoscopic probing or sheath-guided endoscopic probing was used for the initial intubation in all treated eyes, and the stent had been removed at between 2 and 11 months (mean 3.5 months) post-intubation with dacryoendoscopic confirmation of patency and mucosal regeneration. Biopsy specimens were obtained by scraping the recurrent lesion by sheath advancement. Histopathological examination and immunohistochemical (IHC) staining were performed.
Results: In five patients (two males and three females, mean age: 71.2 ± 5.6 years [range: 61–78 years]) with recurrent NLDO, biopsy specimens were obtained from six ducts of six eyes, and stratified epithelium and a mixed inflammatory cell infiltrates were identified. IHC staining was positive for cytokeratin (CK)4 and CK13, and negative for paired box protein Pax-6.
Conclusions: This novel technique enabled a minimally invasive biopsy of the NLD to be obtained, and IHC staining indicated the presence of mucus epithelium, thus suggesting squamous metaplasia of the usual respiratory epithelium which likely occurs secondary to chronic inflammation.
Kalin-Hajdu, Evan; Kersten, Robert C.
Although generally safe, hyaluronic acid rejuvenation of periorbital tissue has been reported to cause minor and major adverse events. The authors document a case of nasolacrimal duct obstruction due to hyaluronic acid rejuvenation of the tear trough. Nasolacrimal duct obstruction immediately resolved following irrigation of hyaluronidase into the affected lacrimal system. To the authors’ knowledge, this is the first reported case of nasolacrimal duct obstruction due to filler injection.
Rong Liu, Hongxun Li, Tao Ai, Weikun Hu, Ban Luo, Nan Xiang
The aim of this study was to explore the pathological changes of the nasolacrimal duct in rabbits with experimentally induced obstructive dacryocystitis in correlation with lacrimal endoscopic findings.
The rabbit model of obstructive dacryocystitis was created by injecting 0.15 ml of self-curing resin into the lacrimal duct. The control group received 0.15 ml of normal saline. Within 16 weeks after the obstructive, lacrimal endoscopy and pathological examination of the nasolacrimal duct were conducted at different time points of 1, 2, 4, 8, and 16 weeks.
In the control group, lacrimal endoscopy revealed pink and smooth mucosa; and the pathological analysis revealed an epithelial layer that was composed of superficial columnar cells and a deep basal epithelial layer. The experimental rabbits showed clinical manifestations of obstructive dacryocystitis a week after the injection of self-curing resin. At weeks 1 and 2, the lacrimal endoscopy showed mucosal hyperemia and hemorrhagic spots on the nasolacrimal duct; and the pathological features included epithelial cell swelling and inflammatory cell infiltration. At weeks 4 and 8, the experimental group showed alternatively red and white mucosa under the lacrimal endoscopy, and the pathological features included proliferative epithelium accompanied by papillary hyperplasia. At week 16, the experimental group showed pale and coarse mucosa and white membrane-like layer covering the mucosal surface, and the pathological features included epithelial necrosis, squamous metaplasia, and sub-epithelial fibrosis.
The mucosa of the nasolacrimal duct showed different pathological features at different time points after lacrimal duct obstruction, which was well correlated with the endoscopic findings. It is possible to predict the pathological stages by the endoscopic observation in NLOD patients.
Schulz, Christopher, B., B.M., B.Sc.; Kennedy, Alasdair, B.M.B.S.; Rogers, Simon, M.B.B.S., B.Sc., F.R.C. Ophth.
Purpose: In evaluating epiphora and its management, the bottom line for all stakeholders is whether an intervention confers any real benefit on quality of life. A review was conducted to identify and appraise patient-reported outcome measures (PROMs) in surgically amenable epiphora.
Methods: A systematic search was conducted of studies relating to surgical intervention for epiphora. Patient-reported outcome measures were identified and assessed against standard criteria.
Results: Of 30,544 identified articles, 227 were eligible for data extraction. Of these, 69% reported a PROM as the primary outcome. PROMs identified included single-item symptom scores (48% of primary outcome PROMs), single-item reports of improvement (30%), the Glasgow Benefit Inventory (3%), Lacrimal Symptom Questionnaire (0.5%), Nasolacrimal Duct Obstruction Symptom Score (0.5%), Ocular Surface Disease Index (0.5%), Visual Function Questionnaire-25, the Short Form-36 Health Survey, and 3 other symptom scores. None were developed through consultation with the target population, and there was inadequate testing of content validity. The strengths and limitations of each PROM are presented, with regard to interpretation, responsiveness, reliability,
Discussion: The importance of robust and psychometrically sound PROMs is essential if the under-reporting of quality of life improvement in patients treated for epiphora is to change. Recommendations for the use of each identified PROM are discussed.
Conclusions: Several PROMs have been used in the recent literature to evaluate patients undergoing surgery to treat epiphora. Assessed against standard criteria, no PROM has proven to be both psychometrically robust and clinically meaningful for use in this population. Future PROM development should be guided by this standard framework.
Sonul Mehta, Gui-Shuang Ying, Ahsen Hussain & John T. Harvey
Purpose: To determine if patients with primary acquired nasolacrimal duct obstruction (PANDO) have an increased prevalence of gastroesophageal reflux disease (GERD) compared to the general population.
Methods: Cross-sectional case–control study. The Mayo Clinic Reflux Disease Questionnaire (RDQ) is used to help physicians diagnose GERD. The retrospective group consisted of patients who previously had a dacryocystorhinostomy (DCR) over a 4-year period by one surgeon (JTH) at one institution. The prospective group included consecutive patients undergoing DCR over an 8-month period for PANDO. The control group consisted of patients at our institution who did not have complaints related to nasolacrimal duct obstruction (NLDO) or a known history of NLDO. The RDQ score or a previous diagnosis of GERD was recorded for each patient. The prevalence of patients with GERD in each of the groups was compared to that in the control group using the Fisher exact test.
Results: Nine (7.7%) of 117 patients in the control group were found to have GERD. Twenty-four of 65 (36.9%) patients in the retrospective cohort were found to have GERD. Twelve of 18 (66.7%) patients in the prospective cohort were found to have GERD. When the prospective and retrospective groups were compared to the control group, the presence of GERD was higher in patients with NLDO (p < .0001).
Conclusion: Based on the results of this study and compared to the general population, GERD has an increased prevalence in patients with PANDO. GERD may have a role in the development of PANDO.
Alam, Md. Shahid; Vaidehi, D.; Therese, K. Lily; Ali, Mohammad Javed
Transient nasolacrimal duct obstruction secondary to a mass lesion compressing the sac or sac-duct junction is rare. The authors report a case of a young female who presented to the authors with complaints of watering and a mass lesion in the lacrimal sac region. An organized perilacrimal mass filled with thick pultaceous material was noted during surgery. Following the drainage of the mass lesion, irrigation of the lacrimal system was freely patent. Microbiological examination and DNA sequencing targeting interspacer region was suggestive of Pleurostomophora richardsiae species. To the best of the authors’ knowledge, this is only the second case report of a subcutaneous perilacrimal mass causing transient nasolacrimal duct obstruction by Pleurostomophora richardsiae.
Ben Limbu, Sulaxmi Katwal, Nicole S. Lim, Michelle L. Faierman, Anna G. Gushchin & Rohit Saiju
We determine whether age is a prognostic factor for surgical outcomes of external dacryocystorhinostomy (Ex-DCR). This retrospective cohort study conducted at Tilganga Institute of Ophthalmology (Kathmandu, Nepal) compared pediatric Ex-DCR procedures (age ≤ 15 years) to adult Ex-DCR procedures (age > 15 years) and was performed between January 2013 and December 2013, with a minimum follow-up period of 6 months. Primary outcome measure was rate of success, defined as complete resolution of subjective symptom(s) of epiphora (subjective success), combined with patent lacrimal passage on syringing (anatomical success) at last follow-up visit. Other outcome measures included clinical presentation, diagnosis, intraoperative complications and post-operative complications. In total, 154 Ex-DCR procedures were included, with an age range of 8 months to 81 years (mean age 36.4 ± 21.0 years). In all, 38 pediatric Ex-DCR procedures were compared to 116 adult procedures. Success rates were 97% in the pediatric group and 95% in the adult group, with no clinically or statistically significant difference in success rate or complication rate between groups (p > 0.05). Our study yielded high success rates of Ex-DCR in both pediatric and adult age groups suggesting that Ex-DCR remains an optimal treatment choice for all age groups. With no difference in surgical outcomes between pediatric and adult patients, including complication rate, we conclude that age is not a prognostic factor for Ex-DCR failure. We do not recommend adjuvant therapy for pediatric patients.